Case studies poor nursing documentation

Case study 1 issue: electronic tools that enable borrowing data from another source electronic tools make it easy to copy and paste documentation from one record to another or pull information forward from a previous visit, someone else's records, or other sources. Case study: documentation and communication posted on april 24, 2014 by admin in uncategorized from the april 2014 aranz medical wound documentation newsletter: an independent nursing home in newport, ri, uses silhouette to help prove the quality of their care, and use the information they gather to guide the best clinical outcomes and provide pressure ulcer surveillance. Examining nursing malpractice: a defense attorney’s perspective kevin giordano he specializes in malpractice defense and is a frequent lecturer at continuing medical education seminars for nurses and physicians. The falls management program: a quality improvement initiative for nursing facilities appendix c case study and program examples previous page next page table of contents the falls management program: a quality improvement initiative for nursing facilities chapter 1 introduction and program overview. Poor documentation and faulty triage were major factors influencing care and legal outcome telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice however, these preliminary results need to be confirmed in a larger sample of cases.

Supporting documentation janet jones is a pre-award specialist for the engineering school she is working on putting in the final edits, and then assembling a grant application prof wilson is submitting tomorrow to the nsf. This is the case study used during the “your medical documentation matters” presentation it is your medical documentation matters 3 case study jk is a 52-year-old male patient he is 6 feet tall and weighs 265 pounds and that jk had not received any wound care prior to admission. Good practices in nursing and midwifery – from expert to expert a manual for creating complete an online request form for documentation, health information, or for permission to quote or translate, on the decided to profile country case studies of good practices in nursing and midwifery.

Medical errors in nursing: preventing documentation errors the importance of proper documentation in nursing cannot be overstated failure to document a patient's condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and the nurse(s. The beside assessment and documentation basics: a pocket card for beginning nursing students is a clinical tool to promote quality, safe care in beginning nursing students first semester pre-licensure nursing students are challenged to acquire and develop the essential knowledge, skills, and attitudes necessary for basic patient care. Hospice documentation in the hot seat presented by: laura montalvo, bsn, rn, cos-c, hcs-d chief clinical officer as required for hospice levels of care • scientific studies demonstrate that there are actual differences in. Coroner’s report: discuss the importance of documentation in health care portfolio activity 2 coroner’s report (2,500 words) as part of your portfolio you are required to review one coroner’s report from the examples provided on the myuni site and provide a discussion with regards to the criteria detailed below.

Jr henry consulting inc wwwemsconsultorg (412) 736-4163 3 ems documentation case studies, compliance and more superior court - june 28, 2002. Expert witnesses are used by both prosecuting and defense attorneys to establish standards of care depending on the kind of legal case, an expert witness could be a nurse, a doctor or a facility facilities caring for the elderly and/or the poor page 5 the best defense is a good documentation offense ii what b. Case note sample narratives an assessor’s case notes have the ability to “tell the story” of a consumer’s medical and social situation in a manner which significantly augments information contained solely from completion of current assessment tools.

This case study, about a developmentally disabled, 30-weeks-pregnant 19-year-old, presents some of the patient management issues that health care workers face the case is used in a graduate level seminar for family nurse practitioner students going th. In a professional negligence case, the plaintiff must prove that care provided by a nurse was substandard by calling upon a nursing expert witness (or, in some states, a physician expert) to establish the appropriate level of care. Nursing documentation 101: community – home care case study page 3 answer key community – home care case study this final case study is based on what you have learned in the course.

  • Scenario 1 pw is a 77-year-old female with a history of upper gi bleed, indeterminate pulmonary nodules, and more recently decreasing functionality at home involving muscle weakness and hand swelling, who presents today for follow-up of her hand swelling and urinary incontinence.
  • Documentation: a case study of the impact on health services funding ping cheng, annette gilchrist, kerin m robinson and lindsay paul dramatically by using nursing case managers’ patient progress summaries’ (curtis, bollard & dickson 2002) the facility for poor care in this instance, patient.
  • Record keeping is an essential part of nursing practice with clinical and legal significance good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care.

Case study 3 issue: patient identification and demographic data: automated patient registration data elements/patient safety risks failure of an ehr system to provide appropriate safeguards against medication errors, including the wrong patient, the wrong drug, or failure to consider all available data, can contribute to poor quality care. Jr henry consulting inc (412) 736-4163 ems lawsuits and documentation issues. The nursing staff’s lack of awareness regarding critical aspects of this patient’s medical condition (eg, history of sleep apnea, use of cpap, and recent acute bronchitis) ultimately impeded the care she received. Find out how inaccurate or incomplete documentation can cause problems with reimbursementand possibly with the law.

case studies poor nursing documentation Reduce your liability risk good documentation can help you defend yourself in a malpractice lawsuit, and it can also keep you out of court in the first place.
Case studies poor nursing documentation
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